MHR: Herpes simplex type 2
meduploader - 05-07-09 22:22

Herpes simplex type 2
Clear, multiple vesicular lesions
No need for diagnosis tests.
RX: acyclovir, valacyclovir or famicyclovir for 7 to 10 days.
Daily suppressive therapy for recurrent genital herpes.
Tzank test: If the roof comes of the vesicle and lesion becomes ulcer of unknown etiology, then the best initial diagnostic test is tzank test. The most accurate test is viral culture.
HY concepts HSV
The use of condoms has been shown to reduce transmission rates of HSV-2 significantly in susceptible women but not in men.
Using condoms during 25 percent or more instances of sexual intercourse was associated with reduced rates of HSV transmission, which suggests that even occasional condom use can protect women from acquisition of HSV-2.
To be effective, the condom must completely cover lesions on an infected man.
Inform patients that asymptomatic shedding is common and that condoms should be used routinely, even when no lesions are recognized
Hospitalization is indicated for patients with genital Herpes if they also have
Symptoms of meningitis: Severe headache, Stiff neck, Photophobia
Symptoms of autonomic nervous system dysfunction: Urinary retention, Constipation , Dysesthesias of the perineal, sacral, or lower back regions
Symptoms of transverse myelitis: Leg weakness , decreased deep tendon reflexes , autonomic nervous system dysfunction
If meningitis is suspected, send CSF for PCR to detect HSV DNA.
Next step: Begin therapy with intravenous acyclovir, 5 to 10 mg/kg every 8 hours. ( do not wait for PCR results to come back if pt has genital lesions suspicious of HSV and has above indications for aggressive therapy)
When symptoms improve, switch to oral therapy for a total of 10 to 14 days of treatment
Recurrences :
For mild, infrequent recurrences ? Episodic therapy is the best. To be efective, it is very important that treatment is started early during prodromal phase or within 1 day of lesion onset. So, counsel pts to recognize the recurrences early and self-initiate the treatment ASAP. Provide prescriptions in advance.
The goal of episodic therapy is to reduce symptoms and to reduce infectivity during the episodes. This therapy does not prevent future recurrences or asymptomatic shedding between the episodes.
Topical Acyclovir is not effective.
For Frequent recurrences  six or more episodes per year START LONG TERM SUPPRESSIVE THERAPY ( ACYCLOVIR/ FAMACYCLOVIR/ VALACYCLOVIR)

Inform patients that continuous suppressive therapy decreases, but does not eliminate, transmission:
Instruct patients taking suppressive therapy to continue to use condoms, although they are only 50% effective in reducing transmission
Explain to patients that treatment is not curative and will not affect the severity or frequency of recurrences when stopped
Inform patients that long-term, continuous treatment is safe and does not require laboratory-test monitoring
Preventing Mother-Infant Transmission
Advise pregnant women to avoid acquiring genital herpes infection, especially late in pregnancy, in order to prevent exposing the infant to herpetic lesions during birth:
In general, recommend abstinence or only protected coital activity in late pregnancy (week 34 onward)
Advise patients that both HSV-1 and HSV-2 can cause neonatal herpes
Inform women that if they acquire HSV 1 or 2 during the third trimester, there is a 30% to 50% chance of transmitting HSV to their neonate
Ask pregnant women regarding h/o genital or orolabial herpes. However, remember 90% of those infected with HSV would deny a history of genital herpes, making history taking of limited value
Advise pregnant women with no history of orolabial herpes or genital HSV-1 infection to avoid vaginal intercourse with a partner who has or may have genital HSV-1 infection and to avoid cunnilingus in the third trimester with partners who may have orolabial herpes, even if no lesions are present at the time of sexual contact
Inform women who do experience their first episode of genital herpes late in pregnancy that:
They are at high risk of perinatal transmission
Mother and child should be managed by a specialist
Cesarean section is generally recommended
Acyclovir treatment should usually be given
Exposed infants often are monitored with surveillance cultures and treated with acyclovir
Identify women who are at risk for reactivation of HSV-2 at time of delivery:
Consider type-specific antibody testing for some pregnant women (or women who plan to become pregnant) and their partners to determine the risk of acquiring HSV-1 or HSV-2, but do not obtain periodic viral cultures from pregnant patients with a history of recurrent genital herpes if no lesions are present
Inform women with a history of recurrent genital herpes that they have a low risk (